| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,589 |
470 |
$297K |
| D7140 |
Extraction, erupted tooth or exposed root |
796 |
331 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
230 |
141 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
227 |
133 |
$27K |
| D9420 |
|
108 |
106 |
$23K |
| D1120 |
Prophylaxis - child |
489 |
480 |
$22K |
| D1206 |
Topical application of fluoride varnish |
644 |
627 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
368 |
348 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
219 |
216 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
324 |
321 |
$11K |
| D1510 |
|
81 |
55 |
$11K |
| D0272 |
Bitewings - two radiographic images |
280 |
274 |
$9K |
| D0240 |
|
360 |
185 |
$9K |
| D2940 |
|
78 |
25 |
$6K |
| D1351 |
Sealant - per tooth |
163 |
62 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
99 |
96 |
$5K |
| D1354 |
|
389 |
94 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
171 |
$3K |
| D2933 |
|
26 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
25 |
$980.56 |
| D9430 |
|
12 |
12 |
$0.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$0.00 |
| D1330 |
|
583 |
573 |
$0.00 |
| D0603 |
|
572 |
562 |
$0.00 |
| D1310 |
|
457 |
448 |
$0.00 |